PCI of Distal LM and Proximal LCx using RotaTripsy Strategy and Single Crossover Stent

CASE & Plan:
75-year-old male with multiple comorbid conditions & COPD presented with CCS class III angina and a positive stress MPI for inferior and lateral ischemia. A Cardiac Cath on September 19, 2023 revealed calcified 2 V CAD + LM disease: 90% RCA-AV Continuation, calcified subtotal occlusion of proximal LCx & 80% distal left main (1,0,1) with SYNTAX Score of 30 and EF 60% . Patient underwent successful intervention of RCA-AV continuation using rotational atherectomy and one (Xience) DES. Patient is now planned for imaging guided staged PCI of calcified distal left main and proximal LCx using RotaTripsy strategy and single crossover stent.


Q What level of angulation would make you not use Rotablator?
A. Any angulation >45degree is associated with higher chances of perforation and hence should be avoided. In rare instances of severely calcified angulations, where no other device crosses, careful rotablation at low speed and smallest burr (usually 1.25mm) may be done.
Q Should angulation mandate the use of a Floppy Rota wire?
A. Yes, as Rota Floppy wire causes less wire biases.
Q What do you prefer doing first in situations where the Rotabur does not cross, like in today's case - downsize or go higher on the burr speed?
A. We usually first increase the speed to 180,000 rpm after 4-5 unsuccessful passage. If burr still doesn’t cross after 3-4 attempts, then downsize the burr. If burr was already 1.25mm, then exchange the Rota Floppy wire to Rota Extra support wire. Despite all these maneuvers, of our 600+ Rota cases annually, we fail to cross the Rota burr in 1-2 cases per year.
Q If even the 1.25 burr did not cross, what would have been your next option?
A. If 1.25mm burr does not cross after 4-5 attempts, then first increase the speed to 180,000 rpm and if still does not cross, then exchange to Rota Extra support wire. Still will be unsuccessful in 1-2 cases per year.
Q No issues having a buddy wire in place with the IVL catheter?
A. Yes, we can use another wire (buddy wire) with IVL balloon with no issues of its performance.
Q Is the new IVL catheter with higher trains of energy helpful?
A. Yes now having 12 pulses (120sec) is very helpful once multi-vessel PCI using IVL is needed (in about 30% of cases).
Q More economical?
A. Higher pulses are economical as we now never have to use >1 IVL catheter in a single case despite MV PCI.
Q So, what is the final answer about IVUS use and operator experience?
A. It seems that IVUS is useful for all the operators, but much for beneficial for low volume operators and in complex cases.
Q Does this IVUS data suggest a greater role of Imaging in Fellowship training?
A. Since IVUS is becoming integral part of our PCI, it is now very important part of the Interventional training. Interventional fellows after graduation from the trining program has to proficient in performing and interpreting IVUS and OCT procedures and images.
Q Can the IVUS data also be expanded to OCT?
A. Yes, many RCT using OCT also have shown the benefit of imaging in PCI.


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